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The United Nations have labelled April 7 World Health Day. A day to pay explicit attention to health issues. Since our focus is trans* and inter*, or differently (and more universally) put: gender identity, gender expression and sex characteristics, this is what we will look into.

Luxury

For transgender persons, or trans* people, or gender variant/diverse people, having a good health is often a luxury they cannot afford. Because they are not recognized as a group in need of specific health care (or even health care at). In many parts of the world including enlightened Europe, wishing to adapt your body’s sex characteristics is a frowned upon phenomenon. Both the general public and the medical sector may despise you for your needs.

Insurance

The next issue is getting the health care covered by insurance. Of the countries that provide health care to relieve the plight of trans* people, most cover maybe the ‘basics’ and then still often on extraneous conditions. These so-called basics are not by definition what the trans* person asks. Because being trans* does not only concern those people who need to ‘switch’ genders for their well-being, but every trans* person who is in need of any health care to increase their well-being with their gendered and sexed body. Some people may need hormone replacement therapy because their natal sex hormones don’t agree with them. Some need to only get rid of (the largest part of) their breasts. And given the choice, the percentage of trans* women that insists in getting rid of their original genitals is not that high. In the Netherlands only 12% of the whole trans* population (estimated at 2 to 3% of the population) decides for medical assistance. Communication from Spain indicates a similar percentage.

Fate

In most countries doctors don’t agree with prescribing hormones or doing surgery upon a patient unless a psychologist has done a thorough assessment of the care user’s mental health and observes the presence of “Gender Identity Disorder” or “Gender Dysphoria”. That process of establishing the diagnosis can easily aggravate the presupposed dysphoria (a word that actually refers to severe depression, and by virtue of that is not a good term). When left to the discretion of a prejudiced medical profession, that has no good understanding of sexual orientation and gender identity (and expression) phenomena, they will try to explain things away, but not legitimize the existence of gender diversity. The higher the level of morals conservatism, the higher the chance trans* people will meet this fate and only can progress medically assisted gender transition with a diagnosis of severe mental disorder.

Standards

Also in the progressive Netherlands you cannot easily enter medically assistance with gender transition. Where the Standards of Care for transgender health care states that informed consent is the way to go, the Amsterdam gender team still insists in a lengthy psychological evaluation and in case you may encounter practical trouble (intensifying ‘dysphoria’, growing life problems for non conforming ..) they may prolong evaluation or when already on HRT, suggest you to lower the dosage. As if that were the issue. Doing so leads to iatrogenic increase of mental instability. Which in turn leads to a decrease of the patient’s health.

Assessment

Another issue that weirdly is coupled to a trans* person’s health, is Legal Gender Recognition and the preconditions for that. In Europe 33 countries require psychological or medical interventions before recognizing a trans* person’s wish to change their gender assignment; 19 still require sterilization and genital realignment. Only two states in the world give the possibility to change one’s gender assignment with no strings attached: Argentina, and Malta. Denmark comes next, but still requires a half-year wait (and being over 18 y.o.). Everywhere else, where there are regulations, psychological assessment is the least invasive requirement, also in the Netherlands. Only two to three countries take trans* people seriously. And only one of these has provisions for a non-male/non-female reassignment.

Malta

Laws and regulations can have an important effect on trans and inter* persons’ well-being. They regulate the conditions for legal gender change, for medical assistance: which interventions are available at all, which ones are insurance funded? For intersex (or inter*, because it can also be an identity and those more ‘intergender’ and the asterisk in both inter* and trans* indicates a vastness in possibilities). Only one state in the whole world, one state out of more than 192 states, prohibits explicitly that sex characteristics get adapted to a social ideal of having genitals clearly distinguishable as male or female. Everywhere but in Malta this is still legal, and standing practice.Progress

Engaging in these usually non-consensual surgeries is a gross violation of a person’s dignity and personal autonomy. Intersex genital mutilations – usually performed on minors – equals forced sterilisation of women for belonging to the wrong ethnic group (forbidden by the European Human Rights Court en the UN!). When asked a paediatrician they sometimes agree that in the past many errors have been made, but nowadays medical science is so much better that the results are incomparable with the sorry state of technique and results of twenty-five years ago. By using that argument they still deny people their right to bodily autonomy, to decide for themselves about their body. They preclude being OK with those genitals (or gonads or chromosomes), with their body and their life.

Power

The health of a person considered physically or mentally deviant is the explicit object of power play, of medical, psychiatric and legal paternalistic laws and practices. That goes against the most basic rights and that alone already is pretty bad for one’s health.

Trans people are seriously disadvantaged by not having accessible trans specific health care. As by not being able to access regular health care because of transphobia and discrimination. Vreerwerk keeps writing and talking about trans health and trans* people’s access to health care. Be it general health care or trans specific. With much discrimination – whether out of ignorance or willingly – trans people are disadvantaged.

We can show how to argue your case using human rights always is being forgotten or submitted to extraordinary requirements to be able to access health care, Vreerwerk offers lectures and workshops – live and on te web – in gaining a human rights background to patients’ rights, to getting your collective health rights.

Vreerwerk has experience in analysing the health rights situation for trans* and intersex people and can help people to advocate for their human rights with regard to good health care that does not discriminate. We are experienced in writing alternative health care standards and have been asked more than once to look at existing practices and advise on them.

We can show how to argue your case using human rights. Central questions here are:

When someone is diagnosed with gender dysphoria you are already ‘too late’. Damage is already done then, the person developed “gender stress”. Now the job is relieve the stress without imposing roles or assuming identities. This is the more true where it concerns minors.

Gender teams have a morbid focus on an imposed psychiatric disorder. Transsexuality or no transsexuality is go or no go. Unhappy but not transsexual? Sorry you are too light. All is focused towards gender reassignment.

Globally speaking some three issues are of great important for trans people to have the possibility for a better life, in accordane to their human rights. These are:

Legal gender recognition

Availability of health care

Legal protection against hate crimes and discrimination

At the 2010 Congenid conference in Barcelona I co-authored the health standards paragraph for trans health. This is meant as a draft for a global trans health policy. Based on total depathologisation of trans identities it clearly states the need for availability and insurance covered trans health care. No one should be left without the possibility to seek medical assistance for gender reasssignment. This is a human rights question.

Using this argument I contacted the Dutch ministry of Health to convince them the Netherlands should plead with the WHO ICD-11 Committee for depathologisation of trans identities, the removal of “Gender Identity Disorder” and reclassification in a different, non-pathological way. Several options can be thought of for this,.

In the Trangender Europe (TGEU) argumentation project”.. And Others” I developed the health care paragraph, giving arguments of trans inclusive health care to activists for policy makers. I have given several talks on this basis (Dublin, Malmö 2010)

Many countries have no possibility for trans people to obtain the trans specific health care deemed necessary to live more comfortable with oneself. Where there is trans specific health care often it is not satisfactory. By stimulating the availability of better information and by advocating for a non pathologising approach we hope to change this. The change process is a great opportunity for cooperation in advocacy.

Big parts of trans negativity and prejudice in health care (as elsewhere) is due to ignorance. Through my experience in European cooperation in developing argumentation for better health carer access for trans people I can help developing a more trans friendly health care and health policy that is trans inclusive.

Together with Transman.nl and in consultation with GATE and TGEU I am now working on an international advocacy project on transgender health care. Through a process of adult education and exchanging ideas we will build an international project aiming for improving trans communities’ capacity in argumenting for good treatment and respectful, non-obligatory, medical interventions based on informed consent. In this proces we want to also enter in a dialogue with national health care and human rights authorities and organizations to raise their awareness on this issue. The project will take place from 2013.

Vreerwerk

A Dutch name for thorough LGBTI advocacy and gender education. More than ten years on the theatre of transgender and human rights with an extra-ordinary personal story, I am the 'tranny' for your cause.